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2014 | 14 | 4 | 235–244
Article title

Rola odbarczenia kostnego czaszki w udarze niedokrwiennym

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EN
The role of decompressive craniectomy in ischaemic stroke
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Abstracts
EN
Malignant ischaemic stroke i.e. one accompanied by extensive oedema bringing about raised intracranial pressure, carries a significant mortality risk as well as a substantial likelihood of permanent neurological deficits. This paper reviews the history of decompressive craniectomy in the management of ischaemic stroke and presents the current views on its usefulness in both supra- and infratentorial infarctions. The surgical technique was looked over along with common complications of surgery. The results of prospective randomised clinical trials: DECIMAL, HAMLET and DESTINY I and II were presented. They have confirmed the role of decompressive surgery in the cases of infarction in the MCA territory. In patients who deteriorate neurologically despite the best medical therapy, decompressive craniectomy, particularly if carried out within the first 48 hours from the onset, yet before the decline of the neurological condition, considerably improves the outcome. Nonetheless, various issues require further studies. The most important ones are: to define the age limit beyond which the patients would not benefit from surgery, to list clearly clinical and radiological indications for decompression, including the cases in which thrombolysis or mechanical revascularisation have been attempted, and finally, to work out the standards of an informed consent for the procedure. To date, no prospective randomised trials assessing the role of surgery in infratentorial infarctions have been conducted. However, on the basis of retrospective studies, suboccipital decompressive craniectomy is strongly recommended in patients with cerebellar ischaemic stroke and decreased level of consciousness, in whom medical treatment failed. The outcome improves along with the better clinical condition at surgery. Ventricular drainage as a single means of decompression does not seem to be indicated whereas its use before suboccipital craniectomy is still a matter of debate.
PL
Tak zwany złośliwy udar niedokrwienny – przebiegający z nasilonym obrzękiem, powodującym ciasnotę wewnątrzczaszkową – obarczony jest znaczną śmiertelnością i ryzykiem trwałych ubytków neurologicznych. W artykule omówiono historię kraniektomii odbarczającej i zebrano aktualne poglądy na jej zastosowanie w leczeniu takiego typu udaru – zarówno nadnamiotowego, jak i dotyczącego móżdżku. Przedstawiono technikę wykonania odpowiednich zabiegów i omówiono ich powikłania. Szczególną uwagę poświęcono przeglądowi wyników prospektywnych badań randomizowanych: DECIMAL, HAMLET oraz DESTINY I i II. Ugruntowały one rolę leczenia chirurgicznego chorych z udarem z dorzecza tętnicy środkowej mózgu. W przypadkach, w których stan neurologiczny pogarsza się mimo terapii zachowawczej, operacja odbarczająca – zwłaszcza przeprowadzona w ciągu pierwszych 48 godzin trwania choroby, przed załamaniem się stanu chorego – znacznie poprawia rokowanie. Niemniej szereg kwestii wymaga dalszych badań. Chodzi zwłaszcza o ustalenie granicy wieku chorych kwalifikujących się do zabiegu, określenie ścisłych wskazań klinicznych i radiologicznych do jego przeprowadzenia, również w przypadkach wcześniejszych prób trombolizy lub mechanicznego udrożnienia tętnicy, a także o wypracowanie standardów związanych z uzyskiwaniem zgody na operację. Do tej pory nie przeprowadzono prospektywnych badań randomizowanych oceniających skuteczność leczenia operacyjnego udarów podnamiotowych. Mimo to zaleca się wykonywanie odbarczenia w przypadkach nieskutecznego leczenia zachowawczego, zwłaszcza w razie wystąpienia zaburzeń przytomności. Wyniki wydają się tym lepsze, im lepszy był stan pacjenta w momencie operacji. Drenaż komorowy jako jedyna metoda odbarczenia nie wydaje się wskazany, a zasadność jego zastosowania jako wstępu do kraniektomii podpotylicznej pozostaje przedmiotem dyskusji.
Discipline
Publisher

Year
Volume
14
Issue
4
Pages
235–244
Physical description
Contributors
  • Klinika Neurochirurgii i Onkologii Układu Nerwowego, Uniwersytet Medyczny w Łodzi, Uniwersytecki Szpital Kliniczny nr 1 im. N. Barlickiego. Kierownik Kliniki: prof. dr hab. n. med. Dariusz J. Jaskólski, dariusz.jaskolski@umed.lodz.pl
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article
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bwmeta1.element.psjd-ab57eea7-85ff-433e-b415-83d27960abd8
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